A system for the Medical Review of nursing home patients has been fully operational in the state of Rhode Island since 1973. This study examines recommendations as to the appropriate level of care required by each of 1,309 skilled nursing patients reviewed during the system's first full year of operation and relates these recommendations to a number of other factors, including patient and facility characteristics. Variables measuring patient medical condition and need for skilled nursing care correlated strongly with level of care recommendations made by the team of professional reviewers. In addition, facility licensing status emerged as a significant influence in the decision-making process concerning appropriate level of care assignments. Skilled nursing patients in multi-level (SN/ICF) facilities were much more likely to be recommended for less intensive, intermediate levels of nursing care than were patients residing in single-level (SN) facilities. This relationship persisted after controlling for variations in patient characteristics, but was strongest among those patients for whom the need for continued SN care seemed most dubious. The authors conclude that 1) the relationship can be attributed to a reluctance on the part of the review team to physically relocate aged patients, and 2) long-term care patients with complexly intertwining medical and social needs might be most appropriately placed in facilities which offer a spectrum of services and multiple levels of care.